The importance of detecting body dysmorphic disorder (BDD) has been emphasized in the literature.1 Nonetheless, BDD is underrecognized and underdiagnosed despite its severity, the availability of effective treatments, and its prevalence. Indeed, BDD is relatively common; in fact, it appears to be more common than schizophrenia, anorexia nervosa, and many other psychiatric disorders (see Didie et al., page 310).
Five studies have found that mental health clinicians fail to diagnose BDD, even when BDD is a major problem or the primary diagnosis.2–6 These studies systematically screened patients for BDD. In all five studies, no patient whom the investigators identified as having BDD had the diagnosis in their clinical record. In one study, the most common reasons patients did not disclose BDD symptoms to their clinician were: the patient was too embarrassed, feared being negatively judged, felt their clinician would not understand their appearance concerns, or did not know treatment for their body image concerns was available.3 Instead, patients may mention only their depressed mood, anxiety, or discomfort in social situations. Thus, clinicians need to systematically screen patients for BDD and recognize clues to its presence.
It is important to recognize and accurately diagnose BDD because BDD is a severe disorder that is associated with markedly poor psychosocial functioning and quality of life, as well as high rates of suicidality (see Didie et al., page 310). In addition, treatment approaches differ from those for other psychiatric disorders (see Phillips et al., page 317, and Veale et al., page 333).
How to Diagnose BDD
Diagnostic Criteria for BDD
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) defines BDD as preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the concern is markedly excessive.7 The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In addition, the appearance concerns cannot be better accounted for by another mental disorder (eg, dissatisfaction with body shape or size as in anorexia nervosa).
Clues to the Presence of BDD
BDD is defined by just these few diagnostic criteria, yet the disorder is complex in terms of its symptomatology (see Didie et al., page 310).8 Because patients may not spontaneously reveal their appearance concerns, clinicians need to be alert to additional BDD symptoms that may be observed by others and may thus provide clues that a person is suffering from BDD. Some clues to the presence of BDD are listed in Sidebar 1 (see page 319).
Repetitive Behaviors (most common)
Camouflaging the disliked body areas (eg, with a hat, sunglasses, make-up or clothes) (91%
)Comparing one’s appearance with the appearance of other people (88%
)Checking one’s appearance in mirrors or other reflecting surfaces (87%
)Excessive grooming (eg, hair combing, hair styling, hair plucking, shaving) (59%
)Reassurance seeking (54%
)Touching the disliked body areas (52%
)Clothes changing (46%
Skin picking to improve appearance (38%
)Tanning to improve a perceived appearance flaw (22%
)Excessive exercise (21%
)Excessive weightlifting (18%
Avoidance of social situationsAvoidance of school or workAvoidance of intimate relationships or datingAvoidance of family eventsAvoidance of other activities that involve other peopleAvoidance of crowded places (eg, the mall) or situations where one’s body may be a focus of attention (eg, the beach, shopping for clothes)Avoidance of bright lightPoor eye contactOther clues include ideas or delusions of reference; depression, anxiety, social anxiety, or suicidality; dissatisfaction with cosmetic treatment for minimal or nonexistent appearance flaws; and the frequently comorbid disorders noted in Didie et al. (see page 310).
These features are not required for the diagnosis of BDD, but they may be clues to the presence of BDD
Adapted with permission from Phillips KA. Understanding Body Dysmorphic Disorder: An Essential Guide. New York, NY: Oxford University Press, 2009; www.oup.com.
As discussed in Didie et al. (see page 310), nearly all patients with BDD perform one or more repetitive behaviors, such as mirror checking, excessive grooming, skin picking, or reassurance seeking. These behaviors can provide important clues that a person may have BDD. Avoidance behaviors may also be a clue to the presence of BDD. Typically, patients with BDD avoid social situations, or they may avoid school, work, or other situations, because they are so self-conscious about how they look and do not want to be seen. Another potential clue is seeking and receiving cosmetic treatment with which the patient is typically dissatisfied (see Crerand and Sarwer, page 344). Patients who evidence any of these behaviors should be asked specifically about BDD symptoms (see Sidebar 2, page 320) to determine whether they have BDD.
Ask, “Are you very worried about your appearance in any way?” Or: “Are you unhappy with how you look?”
Invite the patient to describe their concern by asking, “What don’t you like about how you look?” Or: “Can you tell me about your concern?”
Ask if there are other disliked body areas — for example, “Are you unhappy with any other aspects of your appearance, such as your face, skin, hair, nose, or the shape or size of any other body area?”
Ascertain that the patient is preoccupied with these perceived flaws by asking, “How much time would you estimate that you spend each day thinking about your appearance, if you add up all the time you spend?” Or: “Do these concerns preoccupy you?”
Ask, “How much distress do these concerns cause you?” Ask specifically about resulting anxiety, social anxiety, depression, feelings of panic, and suicidal thinking.
Ask about effects of the appearance preoccupations on the patient’s life — for example: “Do these concerns interfere with your life or cause problems for you in any way?” Ask specifically about effects on work, school, other aspects of role functioning (eg, caring for children), relationships, intimacy, family and social activities, household tasks, and other types of interference.
Questions to Diagnose BDD
Questions to Ask to Diagnose BDD
Sidebar 2 (see page 320) provides some diagnostic questions for BDD. Measures that screen for and diagnose BDD are listed below. The questions in Sidebar 2 (see page 320) closely follow DSM-IV-TR’s diagnostic criteria and are similar to those in the Body Dysmorphic Disorder Questionnaire (see below). It is important to ask the questions in an unhurried and empathic way because patients may be anxious about revealing their appearance concerns for fear that they will be considered vain or will draw unwanted attention to the “ugly” body areas by discussing them.
As shown in Sidebar 2 (see page 320), a useful initial screening question is: “Are you very worried about your appearance in any way?” Or “Are you unhappy with how you look?” It may be helpful to “normalize” the question by noting that many people are unhappy with how they look and then ask if this is a problem for the patient. If the patient replies affirmatively, the clinician can ask the patient to say more about their appearance concerns, such as what body areas they worry about, and then determine whether DSM-IV-TR criteria for BDD are met. It is important to adequately probe for distress and impairment in social, occupational, and other aspects of functioning.
As indicated by BDD’s diagnostic criteria, BDD is diagnosed if the person is excessively preoccupied with nonexistent or slight physical flaw(s) (for example, thinks about them for at least 1 hour a day), which causes clinically significant distress or impairment in functioning. The appearance concerns should not be better accounted for by anorexia nervosa or bulimia nervosa. However, BDD and eating disorders may co-occur,9 in which case both disorders should be diagnosed.
One diagnostic complexity pertains to the diagnosis of delusional BDD (in which patients are completely convinced that their view of their appearance is accurate) versus nondelusional BDD (in which patients have some awareness that their view of their appearance is not accurate). According to DSM-IV-TR, patients with non-delusional appearance beliefs receive a diagnosis of BDD, whereas those with delusional beliefs are diagnosed with delusional disorder, somatic type.7 However, DSM-IV-TR allows BDD’s delusional disorder form to be double coded with BDD; in other words, patients with delusional BDD beliefs may receive diagnoses of both BDD and delusional disorder. This double coding reflects the likelihood that BDD’s delusional and nondelusional variants are actually one and the same disorder, characterized by a range of insight.10 Indeed, BDD’s delusional and nondelusional variants appear to have far more similarities than differences10–12 and, of note, appear to respond to the same pharmacologic treatment (see Phillips, page 325). For DSM-5, a preliminary recommendation is to combine BDD’s delusional and non-delusional variants into a single disorder (BDD).13
Screening and Diagnostic Measures for BDD
The following measures screen for BDD but are not intended by themselves to diagnose BDD. If one of these measures suggests that a patient has BDD, the diagnosis should be confirmed via clinical interview.
The Body Dysmorphic Disorder Questionnaire (BDDQ) is a simple, self-report screening measure for BDD that maps onto the DSM-IV diagnostic criteria.14 The questions are similar to those in Sidebar 2 (see page 320). Adult and adolescent versions are available. In psychiatric and dermatologic samples, the BDDQ has been shown to have high sensitivity (100%) and specificity (89% to 93%) for the diagnosis of BDD.14
The self-report Body Image Disturbance Questionnaire (BIDQ) is a slightly modified version of the BDDQ.15 The BIDQ has been shown to have strong psychometric properties in a nonclinical population. For example, it is internally consistent and converges appropriately with other body image indices.15 Additional research on its psychometric properties is needed.
The Structured Clinical Interview for DSM-IV (SCID) contains a clinician-administered screening section for somato-form disorders, which includes BDD.16 To our knowledge, the sensitivity and specificity of the BDD screening question and, thus, its sensitivity for detecting BDD, is unknown. We suggest that clinicians or researchers who wish to diagnose BDD use the full set of SCID questions for BDD (see below) rather than just the screening question.
The SCID is a semi-structured clinician-administered measure that includes questions to diagnose BDD.16 Advantages are its brevity, simple scoring, and close mapping of the questions onto the DSM-IV-TR diagnostic criteria.
The BDD Diagnostic Module is a semi-structured clinician-administered measure that diagnoses BDD.14 It is similar in format to the SCID and was developed before the SCID included BDD. A version is available for adults and children/adolescents. The BDD Diagnostic Module has excellent interrater reliability (kappa = .96).14 Advantages are its brevity, simple scoring, and close mapping of the questions onto DSM-IV-TR’s diagnostic criteria.
The Body Dysmorphic Disorder Examination (BDDE) is a 34-item semi-structured interview designed to diagnose BDD and measure severity of negative body image.17 Advantages include strong psychometric properties and detailed assessment of symptoms; disadvantages include its length (administration requires 15 to 30 minutes), limited usefulness for patients with more severe symptoms, and complex scoring.
The Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) is a 12-item, semi-structured, clinician-administered scale designed to measure BDD severity.18 The scale’s first three items map onto the DSM-IV-TR criteria for BDD, and extensive clinical experience suggests that a total score of 5 or higher on these three items (including a score of 2 or higher on the distress or impairment items) may be used as a cutpoint to determine the presence of BDD.8 However, methodologically rigorous studies have not been done to confirm this. In treatment studies, a total score of greater than or equal to 20 (when all 12 scale items are assessed) is often considered to reflect clinically significant BDD symptoms.
The Mini-Mental State Examination Plus includes diagnostic questions for BDD, which have the advantage of brevity.19 However, our impression is that this exam may underdiagnose BDD. One question asks whether the appearance preoccupation has persisted in spite of others, including a physician, genuinely feeling that the patient’s worry is excessive. Some patients, however, do not reveal their appearance concerns to anyone, including physicians. In addition, patients typically assume that other people agree that they are truly ugly, even if they are told they look fine.
Differentiating BDD from Normal Appearance Concerns and Other Disorders
To make an accurate diagnosis and institute appropriate treatment, the clinician needs to distinguish BDD from normal appearance concerns. BDD also must be differentiated from other disorders because treatment approaches differ; these disorders include obsessive-compulsive disorder (OCD), major depressive disorder (MDD), social phobia, eating disorders, trichotillomania, panic disorder, agoraphobia, and schizophrenia. The following overview presents a practical approach for distinguishing BDD from some disorders that may be confused with BDD. The Table briefly summarizes why BDD may be missed and how to avoid misdiagnosing BDD as another disorder. More detailed and comprehensive reviews of BDD’s relationship to other disorders have also been published.8,13,20,21
Table. How to Avoid Misdiagnosing BDD as Another Disorder
Distinguishing BDD from Normal Appearance Concerns
BDD must be differentiated from normal appearance concerns to correctly identify those who need treatment. This necessitates a good understanding of the constellation of symptoms that are characteristic of BDD (see Didie et al., page 310).
Studies indicate that appearance concerns are very common in community samples. For example, a large community study found that 56% of women and 43% of men were dissatisfied with their overall appearance.22
Another study in women in a nonclinical setting found that 52% were dissatisfied with their skin, 40% with their teeth, and 40% with their hair.23 However, studies that have examined not only appearance concerns but also the presence of DSM-IV BDD have found that although concerns or even preoccupations with appearance may be common, far fewer individuals meet diagnostic criteria for BDD.
In a sample of 101 German college students, 28.7% were preoccupied with body image concerns; however, only 4% of the entire sample, or 14% of those who were preoccupied, met DSM-IV criteria for BDD.24 In a study in the United States, 87.4% of 2,048 respondents reported worrying about their appearance, but the prevalence of BDD in this sample was only 2.4%.25
Therefore, one of the keys to distinguishing BDD from common and normal appearance concerns is to determine that the individual is preoccupied with appearance concerns. The patient must also (as required by DSM-IV-TR diagnostic criteria) experience clinically significant distress or impairment in functioning as a result of their concerns. Most individuals with BDD also engage in frequent and time-consuming repetitive behaviors and significant avoidance (see Didie et al., see page 310). Although not mentioned in the diagnostic criteria, these symptoms may be clues to BDD’s presence and can help to distinguish BDD from normal appearance concerns. Furthermore, emerging research suggests that people with BDD differ from those without BDD in terms of how they emotionally, cognitively, and visually process certain types of information (see Feusner et al., page 349). Although not directly relevant to diagnosing BDD, such studies are beginning to shed important light on brain processes in BDD and on how people with BDD differ from those without BDD.
Another diagnostic challenge can occur if the patient has an observable physical anomaly, as the clinician must judge whether the defect is slight, as required by BDD’s diagnostic criteria. One guideline is that if the defect is clearly observable at conversational distance without the patient having pointed it out, such a defect would not qualify for BDD. Also potentially challenging are cases in which the patient has concerns about body parts that the clinician cannot see, such as the genitals. However, the patient usually has experienced situations in which others have seen the body part and have given him/her feedback that it is normal appearing and that his/her concerns are excessive.
Distinguishing BDD from OCD
BDD can be misdiagnosed as OCD. Our clinical experience suggests that this error may occur because BDD involves prominent preoccupations and repetitive behaviors, and clinicians may assume that BDD is simply a form of OCD. However, BDD and OCD appear to have a number of differences that are important to be aware of when monitoring and treating patients.20,21
Numerous studies have directly compared BDD with OCD, finding that these disorders have a number of similarities but also some important distinguishing features.21,26–29
OCD and BDD are characterized by recurrent, time-consuming, intrusive, persistent, and unwanted thoughts, which cause anxiety or distress and are usually resisted at least to some extent. Although the form of thought may be similar to OCD, the content is different in BDD because it regards appearance. Nearly all BDD patients perform repetitive behaviors (eg, mirror checking) that are similar to OCD compulsions in that they are time-consuming, difficult to resist or control, not pleasurable, performed intentionally in response to an obsession, and intended to reduce anxiety or distress.
However, unlike what is usually found in OCD, some BDD compulsions do not appear to follow a simple model of anxiety reduction.30 For example, mirror-checking does not reliably reduce distress and often actually increases it, depending on the patient’s perception of their appearance in that moment.
Insight is poorer in BDD than in OCD, with 27% to 60% of BDD patients currently having delusional beliefs versus only 2% to 4% of OCD patients.10–12,28,31–33 The two disorders have somewhat different comorbidity patterns, with some studies finding a higher lifetime prevalence of comorbid MDD and substance use disorders in BDD, and a greater risk of suicidality in BDD.27–29 Importantly, core beliefs in BDD tend to focus more on unacceptability of the self (eg, being inadequate, worthless, defective, or unlovable).34 A prospective longitudinal study that examined time-varying associations between BDD and comorbid disorders indicated that BDD is not simply a symptom of OCD because BDD subsequently persisted in a sizable proportion of subjects following remission from comorbid OCD.35
Distinguishing BDD from Social Phobia
BDD may be misdiagnosed as social phobia because most individuals with BDD have prominent social anxiety, which usually stems from concerns that others perceive them as ugly. Social phobia and BDD share symptoms of anxiety, shame, and self-consciousness in social situations. The primary difference, however, is that individuals with BDD fear negative evaluation due to their appearance, whereas those with social phobia fear negative evaluation due to what they say or how they behave. Social phobia and BDD share high social anxiety and social avoidance, low extraversion, embarrassment, and shame.14,36–38
However, individuals with BDD may have relatively low levels of fear of negative evaluation by others as a person (in a nonphysical sense), which may differ from those with social phobia.14 Importantly, unlike social phobia, compulsions are a prominent BDD symptom.20 The prospective longitudinal study noted above indicated that BDD is not simply a symptom of social phobia because BDD subsequently persisted in a sizable proportion of subjects following remission from comorbid social phobia.35
Distinguishing BDD from Eating Disorders
BDD can usually be fairly easily distinguished from an eating disorder. For example, a patient who is preoccupied with his “misshapen” nose and “small” genitals, and who has no abnormal eating behavior, clearly differs from a patient with an eating disorder. However, it is sometimes difficult to distinguish BDD from eating disorder not otherwise specified (NOS). For example, an individual with BDD may be concerned that her face is too round and may try to diet or exercise excessively to lose weight to make it more narrow. Indeed, BDD and eating disorders share body image disturbance and dissatisfaction.8,13,39,40 Some individuals with BDD, such as those with eating disorders, are preoccupied with body weight and shape and may diet and exercise excessively.8,40
However, there are several important differences between BDD and eating disorders.13 In BDD, dissatisfaction and preoccupation involve more diverse body areas and commonly involve the face or head.39,40 Two studies that directly compared BDD with eating disorders found that those with an eating disorder had greater dissatisfaction and preoccupation with their weight, waist, and stomach, and more psychological symptoms on the Brief Symptom Inventory than those with BDD.39,40 BDD subjects had more negative self-evaluation and self-worth due to appearance concerns, more avoidance of activities due to self-consciousness about appearance, and poorer functioning and quality of life due to appearance concerns.39,40
Distinguishing BDD from MDD
In our clinical experience, BDD is often misdiagnosed as MDD. This may occur because the patient actually meets diagnostic criteria for MDD but does not reveal their appearance concerns to their clinician because of shame or another reason. Additionally, in some cases, the appearance concerns are discussed, but the clinician assumes they are part of MDD symptomatology. In our clinical experience, not diagnosing BDD can lead to persistent BDD symptoms, as well as persistent MDD symptoms, in patients for whom MDD is largely secondary to the distress and demoralization that are typical of BDD.
Individuals with BDD typically share low self-esteem with those with MDD and may also have similar core beliefs and rejection sensitivity.14,20 Some individuals with MDD have generally negative thoughts about themselves that may include their appearance. However, BDD usually involves specific appearance concerns (eg, skin, hair, nose) and time-consuming preoccupations with perceived appearance flaws, rather than just general feelings of low self-esteem. In contrast to MDD, BDD usually involves prominent repetitive behaviors.13
In the previously noted prospective longitudinal study that examined time-varying associations between BDD and comorbid disorders, change in the status of BDD and MDD were closely linked in time. MDD improvement predicted BDD remission over subsequent weeks, and, conversely, BDD improvement predicted MDD remission over subsequent weeks.35 However, BDD did not appear to simply be a symptom of MDD because BDD symptoms subsequently persisted in a sizable proportion of subjects who remitted from comorbid MDD.
Distinguishing BDD from Other Disorders
As shown in the Table (see page 321), BDD can also be confused with other disorders.14 For example, some patients who repeatedly pluck their hair (eg, to remove “excessive” facial hair or to reshape “misshapen” eyebrows) can receive a misdiagnosis of trichotillomania. Those who are housebound may be misdiagnosed with agoraphobia. Additionally, patients with delusional BDD beliefs or delusions of reference are sometimes misdiagnosed with schizophrenia, psychotic depression, or psychotic disorder NOS.